Ruth Armstrong: Lost in the crowd

A FAVOURITE episode of the 1980s British television comedy series, Yes Minister, among doctors must be the one about the hospital with no patients.

When the Minister becomes aware that the state-of-the-art facility is fully built and employing 500 staff but has no patients, he asks incredulously: “Aren’t patients the essential work of a hospital?” The administrator and the Scottish union official leading his hospital tour beg to differ …

This week in MJA InSight we’re looking at large-scale, systemic issues — in hospitals and more broadly — to remind us that the end users are individual people whose lives can be profoundly affected by the choices made at higher levels, as well as the bedside.

Our news begins with a true and much less amusing story from the UK about a health care initiative that started with excellent intentions and ended with a damning report on the state of hospital care, and the abandonment of a widely used treatment protocol: the Liverpool Care Pathway (LCP).

The Pathway was developed more than a decade ago, with the aim of providing guidance for the staff of acute care hospitals looking after patients at the end of life. The idea was to translate hospice-quality palliative care to the hospital wards but, in 2012, stories emerged in the British press of patients started inappropriately on the protocol, families poorly informed, death hastened and end-of-life suffering increased. Sinister claims of financial motivations and euthanasia followed.

Last year, a review recommended that use of the LCP be phased out in UK hospitals, to the surprise of many observers who believed that the problem was with its implementation rather than with the protocol itself. Some Australian hospitals use locally tailored versions of the LCP and, with an MJA ‘Perspective’ article about what should happen here, we sought comment from some local experts.

Hospital funding arrangements are not top of mind for most doctors. Yet if they are poorly calculated, they can lead to wasted resources or deficits in patient care. Another of our news stories, following up on an MJA article on the progress of activity-based funding for Australian hospitals, reveals that the model is set to change again in the 2017–2018 round of funding, with mixed responses on whether this change will increase efficiency and equity, and improve patient care.

MJA research published today confirms that Australian men diagnosed with prostate cancer who live rurally still experience a survival disadvantage. Unpicking diagnostic bias and socioeconomic confounders, as well as age and stage at diagnosis, to discover the relevance to individual patients is difficult. The study design tried hard to do this, and we sought further comment for our second news story.

An interesting Comment in InSight this week reveals that participants of clinical trials often become lost in the crowd when the results are in, rarely hearing about the findings they helped to create. Professor Karen Woolley shares a participant’s view of this situation, and explains from both her research and professional experience why this needs to turn around and how it might happen.

If there was ever a place for individual needs to be forgotten, it is in the aged care system. A career as a geriatrician straddling hospital and aged care has left Dr Ludomyr Mykyta despairing of both. He is non-partisan in his damning of successive Australian governments in his InSight Comment. Mykyta believes passionately that aged care should be part of the health care system and that tailored specialist care should be readily available to residents of aged care facilities.